Name_____________
Date______________
5-6 years
Parental concerns this visit: ________________________________________________________
________________________________________________________________________________
Current Medications: ________________________________________________________
Current Allergies: ___________________________________________________________
Family
After school care ___yes ___no school:____________________
Changes since last visit _________________________________________________
Diet
5 servings of fruit/vegetable ___yes ___no
Limited sweetened liquids ___yes ___no
Vitamins/Supplements __________________________________
Diet Concerns ___yes ___no
Diet comments ____________________________________________________________
Sleep
Sleep concerns ___yes ____no
Tobacco Exposure ____yes ____no
Behavior Concerns ____yes ____no
Physical Activity Play time (60m/d) ___yes ___no
Screen time (<2hr/d) ___yes ___no
School
Grade _______ Special education ___yes ___no
Social concerns ____yes ___no Social interaction _______________
Performance concerns ____yes ___no
Behavior concerns ____yes ___no
Attention concerns ____yes ___no
Homework concerns ____yes ___no
Parent/Teacher Concerns ____yes ___no
comments: ____________________________________________________
Parent child interact concerns ____yes ___no
comments: _____________________________________________________
Cooperation concerns ____yes ___no
Development
Language: ___ Good articulation/language skills
Learning: ___ Draws person (6+ body parts)
___ Prints some letters and numbers
___ Copies squares, triangles
___ Counts to 10
___ Names 4 or more colors
___ Follows simple directions
___ Listens and attends
Motor: ___ Balances on 1 foot
___ Hops and skips
___ Able to tie knot
Additional comments: ____________________________________________________________
________________________________________________________________________________
